BLOGGERS: MARK SCHOLZ, MD & RALPH H. BLUM

Tuesday, May 28, 2013

BY MARK SCHOLZ, MDOsteoporosis is the medical term for “weakened bones” resulting
from the slow leaching of calcium over time. Osteoporosis is incorrectly thought
to happen only in females. However, one-third of hip fractures occur in men and
are associated with higher mortality rates in men with prostate cancer. Calcium
loss is a silent process until a fracture suddenly occurs. Common fracture
sites are spine, rib, wrist, and hip. Compression fractures of the spine can be
quite painful and result in loss of height with forward curvature of the spine.

Cause of OsteoporosisJust as there is a link between lack of estrogen and osteoporosis
in women, studies show that there is also a relationship between a lack of
testosterone and osteoporosis in men. Other causes of osteoporosis are thyroid
or parathyroid hyperactivity, excessive alcohol, cortisone, lack of exercise, low
vitamin D and low calcium intake. Osteoporotic fractures also occur more
frequently in men taking testosterone inactivating pharmaceuticals (TIP).

Detecting Osteoporosis

Osteoporosis, when it is diagnosed at an early stage, is easier to
treat. Unfortunately, the most common scanning technique for diagnosing
osteoporosis, the DEXA scan—grossly underestimates the degree of bone mineral
loss from the spine in men. Why? Because almost all men over fifty have calcium
deposition in the ligaments surrounding the spine. When the DEXA is used to
measure bone density, the excess calcium in the ligaments causes an incorrectly
“normal” bone density reading.

Fortunately there is a better technique called QCT that measures bone mineral
density in the center of the vertebral column. Awareness of the DEXA scans'
limitations in men is under appreciated by many physicians even though these
limitations have been well documented in a study from Massachusetts General
Hospital. In this study 41 men underwent both DEXA and QCT scanning. QCT
detected osteoporosis in 26 of the men (63%) but DEXA only diagnosed it in two (5%).

Preventing Osteoporosis
Osteoporosis treatment begins with an exercise program. Supplementation with
calcium and vitamin D should also be considered routine. We recommend 500 mg of
calcium at bedtime and a starting dose of 1,000 units of Vitamin D. Blood
levels of vitamin D should be checked and oral intake of vitamin D adjusted
accordingly. Studies show that using TIP
intermittently (compared to continuous TIP) results in less bone loss.Treatment
with bisphosphonatesor denosumab (see below) can prevent
TIP-induced bone loss.Osteoporosis
MedicationsOsteoporosis can be reversed with bisphosphonates or denosumab.
Normal bone metabolism is a balance between the rate of bone breakdown and the
formation of new bone. Osteoporosis occurs when the formation of new bone lags
behind the rate of bone breakdown. Bisphosphonates and denosumab function by
slowing the rate of bone breakdown, allowing the osteoblasts, the cells that
form new bone, to increase the net amount of bone matrix.Oral Medications: Boniva, Actonel and
FosamaxBisphosphonates come in both oral and intravenous forms.
Absorption into the blood of oral forms is enhanced when they are administered
with an empty stomach. The most common side effect from oral bisphosphonates is
stomach or esophageal irritation which can be minimized by maintaining an erect
position for an hour after taking the drug.Intravenous
Bisphosphonates: Zometa (zolendric acid)Intravenous administration of Zometa has the advantage of
bypassing the stomach thus avoiding concerns about stomach irritation. Also with
the intravenous approach 100% of the drug gets into the system as compared to
the oral preparations that are only 1-2% absorbed. The most common side effect
from Zometa is a brief flu-like muscle soreness lasting a day or so. These
symptoms do not usually recur on subsequent infusions. For the treatment of
osteoporosis the infusions are repeated every three to six months.

Denosumab
Injections: Prolia and XgevaLike Zometa, denosumab inhibits the osteoclasts, but by a
different mechanism.Denosumab is
marketed in two strengths for injection. A half-dose shot called Prolia is
administered every 6 months for osteoporosis.A full dose shot called Xgeva is given monthly for cancer metastasis to
the bone.

Medication
Induced Jaw Problems: Osteonecrosis
Zometa and denosumab and to a much lesser degree, oral bisphosphonates can
rarely induce damage to the jaw, a condition termed osteonecrosis.The risk of developing osteonecrosis is much
higher when a tooth is extracted. When osteonecrosis occurs, the gum tissue
recedes leaving exposed bone which is susceptible to recurrent infections. The
risk of osteonecrosis becomes higher as the lifelong cumulative medication dosage
increases. In my experience, osteonecrosis almost always reverses, albeit
slowly, after the medication is stopped.

Bone Metastases

Zometa and denosumab are also FDA approved to treat cancer that has metastasized
to bone. Their anticancer effect is believed to occur because by inhibiting bone
breakdown, cancer cell access to the growth factors and cytokines that are
normally locked up in the bone matrix is blocked. So these medications that
inhibit bone turnover by stopping osteoclast activity not only help
osteoporosis but also help to prevent bone metastases from progressing.

Final
thoughts

Eventually some degree of osteoporosis occurs in most men as they
age.Regular exercise, calcium and
vitamin D help delay bone loss.Bone
density screening in men should probably begin when they are in their 60s, so
the condition can be detected early.Bone density augmentation with denosumab or bisphosphonates seems to be
more effective when osteoporosis is not too severe at the start of therapy.

Tuesday, May 21, 2013

Side effects vary from patient to patient and are influenced by types of
testosterone inactivation pharmaceuticals (TIP) used, and by the duration of
treatment. However, a number of interventions are available that can substantially
reduce these adverse side effects.

Loss of Libido
Libido is an emotional attraction to the opposite sex (in most cases). Libido
is not the same thing as potency, which is defined as the ability to get an
erection. TIP causes loss of libido about 90% of the time. Libido returns when TIP is stopped though
some men say libido after TIP is chronically diminished. Loss of libido and the
cessation of sexual activity has wide ranging ramifications far beyond the
intended scope of this blog. Specialists in sexual counseling are available and
can be of great assistance.

Erectile
Atrophy
Whether or not couples continue to have sexual intercourse after treatment, we
counsel men to induce daily erections to counteract the risk of penis
shrinkage. Cialis or Viagra should be taken daily.If this fails to restore the normal pattern
of nighttime erections then either a vacuum pump or injection therapy should be
considered.

Muscle Atrophy
Muscle mass can be maintained with a strength training program. Walking,
aerobics, and stretching are healthy but accomplish little toward building
muscle mass. Strength training that is effective requires a program similar to
that undertaken by body builders. Ideally,
strength training requires a minimum of two, one-hour sessions weekly during
which all the major muscle groups are exercised: Pectorals, Deltoids, Biceps,
Triceps, Latissimus dorsi, Upper and lower back muscles, Abdominals, Gluteus,
Quadriceps, Hamstrings, and Calf muscles. Three sets of 10-12 repetitions
should be undertaken with weight selected to result in muscle failure toward
the end of the third set.

Fatigue and Lassitude

Tiredness and weakness from TIP are a direct result of muscle loss
and reversible with strength training. Strength training is very effective for
counteracting fatigue. Men who begin strength training when they initiate TIP
will not only forestall tiredness, they can actually increase their strength.Osteoporosis
TIP causes accelerated calcium loss from the bones, termed osteoporosis.
Untreated bone loss can result in hip and spine fractures. Osteoporosis can be
prevented with medications such as Prolia, Xgeva, Zometa, Boniva, Actonel and
Fosamax which should be initiated when TIP is started. See the booklet titled Osteoporosis available** soon at www.prostateoncology.com
for further details.

Hot Flashes
Hot flashes occur in about two-thirds of men on TIP. When severe, a progesterone
injection (depo provera) can dramatically
reduce hot flashes. Other prescription medications, which are effective about
half the time, are low dose Effexor, a medication approved for the treatment of
depression, and Neurontin, a medication approved to prevent seizures.
Transdermal estrogen patches are very effective but sometimes cause breast
enlargement or nipple tenderness.

Weight Gain
TIP slows metabolism causing weight gain. Keeping a stable weight is easier
than trying to lose weight. It is wise to evaluate your diet at the time of
starting TIP to see if fat and sugar intake can be reduced. See the brochure
about diet from the PCRI for more details.

Breast Growth
Breast growth (even without estrogen patches) occurs frequently in men treated
with Casodex monotherapy and less frequently, about one-third of the time, in
men treated with other forms of TIP. If there is any evidence for breast growth
or nipple tenderness, therapy with an estrogen blocking pill called Femara
should be started immediately.Alternatively, a short course of radiation to the nipples can be
administered prior to starting TIP.

Anemia
Blood is a mixture of red cells and "serum" (water). When the
proportion of red cell is diminished it is termed anemia. Severe anemia can cause shortness of breath. Milder degrees
cause fatigue. Anemia reverses when TIP is stopped. If anemia is severe, it can
be corrected with a medication called Aranesp. Iron is not beneficial.

Arthritis
Joint pains particularly in the hands but sometimes in other joints are common
and often improve with glucosamine, Motrin or Celebrex.

Liver Changes
Casodex and Flutamide occasionally cause serious liver problems. This is
detected by blood tests that need to be done routinely after starting TIP. The
problem is easily reversible if detected early and the medication is stopped.

Mood Swings
Men on TIP occasionally mention increased intensity in their emotions. Some
find this effect unpleasant whereas others enjoy it. For men with the former
attitude, low doses of medications such as Zoloft or Paxil can reverse the
unpleasant feelings.

Final Thoughts
My general impression after many years treating men with TIP is that treatment
is quite tolerable if side effects are expertly managed. Preventative measures
such as weight lifting and diet are critically important. Checking blood tests
for anemia and liver function is essential. Side effects like joint pains, hot
flashes, depression, emotional swings, breast enlargement and impotence can be
greatly reduced with judicious medical care.

Tuesday, May 14, 2013

There is no doubt that all the main prostate cancer
treatments—surgery, radiation or hormone therapy—are likely to affect
erections. And although many men who are diagnosed with prostate cancer are
older, and may therefore already besubject
to the ordinary fatigue and malfunctionof
nature’s ultimate erector set, the degree to which sexual function returns—or
fails to return—after treatment is still a matter of major concern for a number
of us.

There is no set formula or predictable schedule for recovery
of sexual function after prostate cancer treatment. If you choose surgery, your
chance of recovering potency is partly dependent on the experience and skill of
your surgeon. The minuscule nerves that control erections are located dangerously
close to the prostate, and damage to or actual removal of those nerves during
surgery causes permanent erectile dysfunction. Viagra or Cialis only works if
the nerves can be spared. And even with successful nerve-sparing surgery
it can take up to 12 months for the restoration of the natural ability to have
an erection.

The
radiation options—seed implants or IMRT—are associated with a significantly
better chances for maintaining erectile dysfunction. But the reality is that
radiation therapy still can cause
erectile dysfunction because of the inflammation or scarring that occurs around
the nerves.

Hormone
therapy, another treatment alternative, causes total dissolution of sex drive, and you don’t even care that it’s gone!
Fatigue, joint pain, depression and hot flashes are not exactly a turn-on
either. And yet even without a libido, an erection can be achieved through the
manipulation of modern pharmacology—that is if you can dredge up enough desire
to give it a try for your partner’s sake—but even with a pharmacological
assist, personal satisfaction is often seriously diminished.

There
is, moreover, a “use it or lose it” caveat: many doctors who specialize in
erectile dysfunction encourage sexual activity as soon as possible after
treatment (or in the case of hormone therapy during treatment) on the grounds that the nerves and muscles that
control erections can atrophy if they are not used for a long period of time.

If
prostate cancer has already affected your ability to achieve erection, there
are various options that might help—penile injections, a vacuum pump device,
implantable pellets, or penile implants. I will present the pros and cons of
these methods for inducing an erection in my next Blog. In the meantime, keep
in mind that there are ways you can express your love for your partner and
attain sexual gratification that don’t include penetration. Ways that include
intimacy and tenderness, lest we forget.

Tuesday, May 7, 2013

Many
men with Intermediate-Risk prostate cancer consider treatment with
radiation or surgery. Treatment selection is influenced by age and preexisting
status, especially as regards baseline sexual and urinary function. These days
“surgery” usually means robotic surgery rather than the older, “open”
procedure. Brachytherapy (radioactive seeds), and intensity modulated radiation
(IMRT) are the most widely used types of radiation.

Cure
Rates

All
treatment options result in similar cure rates assuming the best physicians and
technology are used. If any single treatment can be considered to have a slight
advantage, it is brachytherapy. Seed implants deliver a somewhat higher dose of
radiation, possibly with slightly better accuracy. All types of radiation have
a slight cure-rate advantage over surgery because radiation treats a small margin
around the gland. Surgery, especially when extra-capsular disease is
present, may leave cancer behind, an unfortuante situation called “a positive
margin.”

Quality
of Life

Since
cure rates are equivalent, the main criteria for selecting treatment are side
effects. Table 1 lists the risks faced by a 65-year-old with good erectile
function and without preexisting prostate problems. Risks are adjusted up or
down based on a man’s age and his sexual and urinary function prior to
treatment.

Table
1 Long Term Side Effects

Impotence

Incontinence

Climacturia*

Urethritis

Stricture**

Proctitis

Surgery

50%

8%

15%

-

5%

-

Seeds

30%

1%

-

10%

2%

1%

IMRT

30%

1%

-

4%

2%

2%

*Climacturia
is the ejaculation of urine rather than sperm

**Stricture
is a urethral scar

Short Term Side Effects
Some of the long-term effects noted in Table 1 also occur short term. All men
are impotent after surgery though 50% eventually recover some functionality.
Urinary symptoms, termed “urethritis,” occur in two-thirds of men who undergo
brachytherapy, usually lasting a couple months. Proctitis symptoms lasting one
to two months occur in about half of the men who are treated with IMRT.

Treatment for Long Term Side Effects

Shrinkage
and shortening of the penis due to surgery may be partially averted with early use
of Viagra, Cialis or Levitra, and when necessary, the injection of
prostaglandins. For treating impotence or incontinence, patient satisfaction is
about 85% with a surgically implanted penile prosthesis and 60% with a
surgically implanted artificial urinary sphincter. Chronic urethritis, a
non-healing radiation burn of the urinary passage, manifests as pain, frequent
urination, and a compelling urge to urinate right now. Proctitis side
effects can be described similarly, but affecting the rectum. Palliative
treatments for chronic urethritis and proctitis are only partially effective.

Further
Aspects of Surgery and Radiation

Surgery:
The
surgical skill of urologists varies and is measured by how frequently cancer is
left behind after the surgery, termed a positive margin. The best
surgeons average a 10% rate. Studies show that many urologists, even at
reputable centers, leave cancer behind up to 50% of the time. Prostate removal
gives information about the size and grade of the cancer, helping to improve the
accuracy of projections about future relapse. Surgery also simplifies PSA
monitoring, since unlike radiation, there is no residual prostate gland
producing PSA.

Seeds: Brachytherapy with permanent seeds is an outpatient procedure.
Temporary, high-dose-rate (HDR) brachytherapy requires an overnight stay in the
hospital. Men with preexisting urinary problems or glands over 60cc are more
prone to develop urethritis from brachytherapy. A benign PSA rise after the
implant, termed a “PSA Bump,” occurs in 30% of men and can engender
considerable anxiety.

IMRT treatment requires two months to deliver. Radiation beaming through
surrounding organs may increase the risk of bladder and rectal tumors, though
the risk is clearly less than one percent. The biggest risk besides impotence
is proctitis. In the future, the injection of hydrogel between the prostate and
the rectal wall may eliminate this risk (Hydrogel is pending FDA approval).

Cyberknife and Proton Therapy: Cyberknife is like IMRT but treatment is
over one to two weeks rather than two months. Proton therapy is also similar to
IMRT except it fires heavier subatomic particles (proton vs. photon). Proctitis
rates are reported to be slightly higher with either of these two modalities.

Combination Radiation with Seeds and IMRT: Men with High-Risk
disease and even some with Intermediate-Risk are treated with a
combination of Seeds and IMRT. The side effects of Seed/IMRT combinations are
similar to those of seeds alone.

The Outdated Sequencing Argument
As stated at the outset, cure rates are high with both radiation and surgery.
Arguments touting surgery as the “Gold Standard” were true ten years ago when
suboptimal radiation resulted in lower cure rates. Regrettably, to this day,
many surgeons are still claiming that sequencing surgery before radiation is
advantageous. This outdated thinking prioritizes planning for relapse,
forgetting about the need to focus on quality of life. The goal is to be cured
with the first treatment and be spared the side effects of additional rounds of
therapy.

Taking Time to Decide
Prostate cancer is slow moving condition. There is no need rush to a decision.
Radiation or surgery cures men with Intermediate-Riskprostate cancer
70-90% of the time. Even if a relapse occurs, salvage therapy usually gives a
normal life expectancy. Additional options, besides surgery and radiation, can
also be considered for men in the Intermediate-Risk category including
active surveillance, focal therapy and intermittent hormone blockade. However,
these treatments are outside the medical mainstream and beyond the scope of
this short blog.

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PROSTATE SNATCHER VIDEOS

MARK SCHOLZ, MD

Mark Scholz, MD is board certified in medical oncology and internal medicine. He has been treating men with prostate cancer exclusively since 1995. He is the Medical Director of Prostate Oncology Specialists, Inc., and Executive Director of the Prostate Cancer Research Institute. He is an acknowledged expert on management and treatment for prostate cancer using hormone intervention, immunotherapy, chemotherapy and angiogenesis as well as vitamin, herbal and other forms of lifestyle counseling. His affiliations include St. John's Health Center, Marina del Rey Hospital and others. Dr. Scholz also served as an associate clinical professor in the department of Oncology at USC School of Medicine. Dr. Scholz volunteers for the Internet list “Patient to Physician,” found via Resources at www.pcri.org . You may also find current posts on twitter. www.twitter.com/markscholzmd

RALPH H. BLUM

Ralph H. Blum is a cultural anthropologist and author, graduated Phi Beta Kappa from Harvard University with a degree in Russian Studies. His reporting from the Soviet Union, the first of its kind for The New Yorker (1961—1965), included two three-part series on Russian cultural life. He has written for various magazines, among them Reader’s Digest, Cosmopolitan, and Vogue. Blum has published three novels and five nonfiction books. He has been living with prostate cancer, without radical intervention, for twenty years.

PROSTATE ONCOLOGY SPECIALISTS

Established in 1995, Prostate Oncology Specialists has earned national acclaim for its comprehensive approach to prostate cancer prevention and management. Under the direction of Medical Director Mark Scholz, M.D., Prostate Oncology Specialists employs a highly skilled team of physicians trained in oncology, radiology, hematology, and internal medicine who treat all stages of prostate cancer. Prostate Oncology Specialists are not wedded to any single therapy for prostate cancer, but rather advocate the exploration of treatment options that are customized and tailored to the unique needs of each individual patient. Treatments employed include active surveillance, testosterone deprivation, partial cryotherapy, seed implantation, intensity-modulated radiation, and surgery. Prostate Oncology Specialists’ ongoing mission is to uncover new medical breakthroughs in the treatment and management of prostate cancer.

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